Metabolic and Endocrine considerations after major Burn injury

We shall never forget that the burn patient is the ultimate expression of a long lasting and sometimes fatal SIRS (systemic inflammatory response syndrome), this pro-inflammatory response is designed to limit the initial injury and prevent spread. The response will generate, the early compensatory anti-inflammatory response (CARS), to maintain immunologic balance, when the strength of the pro-inflammatory SIRS response predominates the compensatory anti-inflammatory response (CARS) becomes excessive and can result in immunosuppression or immune paralysis. An exaggerated CARS response can make the individual susceptible to nosocomial or secondary infections which can lead to marked by multiple organ dysfunction/failure and has been termed immunologic dissonance and is manifest as an inappropriate or out of balance immune system that results from persistent dysregulation of the SIRS and CARS response.Severe burn injury is followed by a profound hypermetabolic response that persists up to 2 years after injury. It is mediated by up to 50-fold elevations in plasma catecholamines, cortisol, and glucagon that lead to whole-body catabolism, elevated resting energy expenditures, and multiorgan dysfunction.After any significant injury, there is a compensatory decrease in tissue perfusion and a decrease in metabolic rate: the ebb phase. Subsequently, there is a hyperdynamic state characterized by increases in metabolism, and hyperdynamic circulation: the flow phase. In severe burns, the ebb phase lasts up to 72 hours after injury. The subsequent magnified flow phase in severe burns can be limitless in time and physiologic consequence. When left untreated, there is a physiologic exhaustion, and the injury becomes fatalThe understanding of this physiological hypermetabolic responses known as the flow phase, has significantly improved morbidity. Many therapies have been tested to modify this catastrophic response and improve outcome, such as early excision and grafting of burn wounds, thermoregulation, control of infection, early and continuous enteral feeding with a high-carbohydrate high-protein diet, and pharmacologic treatments with anabolic agents, such as growth hormone, insulinlike growth factor-1 (IGF-1), insulin, oxandrolone, propanolol aimed at mitigating physiologic derangements.The future resides in achieve the right combination of attitudes to obtain the balance in modulation of the hypermetabolic response and modification of hormonal response, to obtain the best outcome in major burn injury.